Provider Demographics
NPI:1770544967
Name:GARDNER, RICHARD D (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2420
Mailing Address - Country:US
Mailing Address - Phone:304-523-1142
Mailing Address - Fax:304-523-2966
Practice Address - Street 1:1415 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2420
Practice Address - Country:US
Practice Address - Phone:304-523-1142
Practice Address - Fax:304-523-2966
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP21089Medicare UPIN
WVPA16313Medicare ID - Type Unspecified